126801871-8-4-2022-21-AS-BMOS-CH6UHR-20220810153621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:55:14 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20220802120803

FACILITY NAME:	ALDER BAY ASSISTED LIVING		FACILITY NUMBER:	126801871
ADMINISTRATOR:	IVORY, JOH-NIKA		FACILITY TYPE:	740
ADDRESS:	1355 MYRTLE		TELEPHONE:	(707) 444-8000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95501
CAPACITY:	49	CENSUS: 35	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tiffany Blake		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Unqualified Administrator working at facility

INVESTIGATION FINDINGS:

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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility, unannounced, to open an investigation into the above allegation. LPA met with Executive Director Tiffany Blake and reviewed documents. Tiffany told LPA she submitted the administrator application on 10/20/2021. Then again, after taking and passing the Administrator test. Tiffany told LPA that her payment was returned due to it being the wrong amount. A new check, for the proper amount, was sent, which was also returned, due to the date being past the 30 day time frame from taking the test. Although it appears there was some miscommunication between Tiffany and the Administrator certification unit, no application was received, therefore no Administrator certificate was issued. LPA discussed the steps that need to be taken to correct this issue.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Tiffany Blake and Appeal rights were given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220802120803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALDER BAY ASSISTED LIVING	FACILITY NUMBER: 126801871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2022 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties:(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on interviews	1 2 3 4 5 6 7	Licensee to ensure a person with an active administrator certificate is at facility. Current administrator will obtain Administrator certificate and submit evidence to CCL by POC Date of 08/26/2022.
	8 9 10 11 12 13 14	conducted and records reviewed, Licensee did not ensure a currently certified administrator was at facility. This poses a potential health, safety or personal rights risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

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